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Exhibit E
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page Information and named theCertificate on to is certificateissued theOwner This the may examtne Group PolicyYou the undel Group coverage the evidences lnsured's of the inconsideratton is This pofi.V theoffice thepolicyilolder, certificateissued of ut of and application payment premiums' the dres if benefit thelnsured before we pay is While certiflcate ineffect, witt thedeath this to subject thiscertificate's will payment bemade of rxfi6tionDate anyterm.Any provisions, is of This CAREFULLY. certificate lifeinsurance partof a legal CERTIFICATE YOUR READ and ierms contains This and thepolicyholder theCompany. ceriificate between contract Policy' the under Group to that provisions areapplicableallOwners for Signed theComPanY'
·OE
· g m , Ý
·]
·ç President
AGENT NAME AND ADDRESSi PATRlCE PFITZER P o Box127 FOLSOM,CA 95763
c F ·· ablel ·· apÏ countersigned at
City: ByAgent:
State:
Date
return within20days it this not lf TO RIGHT CANCEL. youdecide to keep certificate, to or to maybereturned anyof our agenis it maybemailed us' it. receive lt .ft., yo|.l paid Any witt this certificate voidit fromthe beginning' premium will in, ,Ltutnof of within10daysof ourreceipt thiscertificate' any We berefunded. will make refund CERTIFICATE LIFE INSURANCE TERM TEVEL GROUP
LIFE TERM
questions lf T0 NOTICE OWNER: youhave or this about cedificateif orne*dinfotmation a complaint, in resolving assistance vouneed 3-8797 call olease usat 1-888-51
Expiration and is the while Insured alive untilthe in are Premiums payable advance premium will renewal each Period, Guarantee Premium term. Afterthe of Eate each OF in shown theTABLE TotalPremium Maximum thantheGuaranteed not bemore if is to Renewable age95. Deathbenefit payable PREMIUMS, nt-flqU* RENEWAIis in effect' Date the dies lnsured before Expiration andwhilethiscertificate are dividends notpayable Nonparticipatingl
99) C(12·] FGL RTRC·]
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Page BENEFICIARY of ................. Change Beneficiary(ies) Beneficiary(ies) lrrevocable ,,,, to PaymentBeneficiary(ies) ,,,..,.,,.,.... ,W ,W ,W ,W
OWNERSHIP
Owner Change Owner Contingent of and Rights Ownership Ownership Succession PREMIUMS Premium$....... Adjustment of Renewal Grace Period.. Premium Payments Renewal.........
1 .......................,. REENTRY OPTt0N......... 1 ................ New Ceriificate 1 and Suicide Incontestabi|itv.........................
1 ...................... RETNSTATEMENT .....,......... 1 ............. Effective of Reinstatement Date .....,..,.,,,..,, 1 Reinstatement Reouirements
follow 16, benefits Page restrictions, oradditional riders, Any endorsements,
Page 2
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3 Page
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4 Page
ED ON rTA3LE CONrlNÒ NEXTPACEl
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Page (Continued) 4
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4 Page (Continued)
EE1 01V IVEXTPACFl F COIVTINÒ fTABÇ
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Agelnsured'sAgeonhisorhernearestor|astbirthday. Beneficiary the to on change record receive death recent or in named theapplicationin themost Theperson(s) benefit. due Premium dates, starts. coverage on premium dueand which is the on Thedate which initial from are years, anniversariesmeasured thisdate' and months, ceriificaie the to change record receive death on recent or in named theapplicationinthemost Theperson(s) death. at is not if benefii theBeneficiary alive thelnsured's of the to on change record become owner recent or in named theapplicationinthemost Theperson(s) the dies if the certificate Owner before lnsured' this
Date certificqte
contingent Beneficiary contingent Owner
Date Expiration
Amount Face policy Group lnsured
renewa, fiH!,Jlililll'15Jil.il"'lfiHHT#?oeJanv l[--+?l:#rH5lrTl;"?'--;tHiplSru Date' preceding Expiration
the after is term oneyear DATA CERTIFICATE in under is and in coverage effect which shown life of Theamount ierm insurance section' INFORMATION theCERTIFICATE is which certificaieissued, this Policy Term Insurance under Life TheGroup life section INFORMATION whose is DATA CERTIFTCATE in iheCERTIFICATE under named Theperson this under ceriificate. insured who on recent change record, isentitled or in in as named Owner theapplication, themost Theperson(s) certificate' in rights totheownership staled this section' INFoRMATION OERTIFICATE under Policy shown as of Theowner iheGroup
'wner policyhotder
We,our,Us,CompanyFidelityandGuarantyLife|nsuranceCompany. Request written (if dated, notarized required and must request besigned, by io written usandreceived us. That A request to on bytheform) a fom sati$factoryus, TheOwner,
Your You.
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Owner, Contingent Owner, Beneficiary, inevocable Beneficiary, Contingent to AnyreferenceBeneficiary, persons. payee, include multiple may and/or
Contract Entire
of: and beiween Conkactholder usconsists the contract Theentire contraci, 1.TheGroup a of and is a copy application, oi which attached made part theContract; 2.TheContractholdels and are which attached; and endorsements riders, 3.Allamendments, panicipant. as contract to each 4,Theentire participant of: consists contracl t0 each as Theeniire contract; 1,TheGroup 2.This Certifiate; and a of and is of a cgpy which aitached made part thisCertificate; 3.Theapplicaiion, page(s) is INFORMATION which attached riders endorsements, or anyCERTIFICATE 4. A1amendments, address. last to to ormailed your known 0r to can Office agree change waive in PresidentourHome or the Only president, Secretary,a Vice the be must inwriting. or The conkact. change waiver provisions arepart theentire of which any
Representations
will statements bemnsidered Those made on Wewiltrely allstatements in anapplication. unless that of in We and representationsnotwarranties. willnoiuseanystatementdefense a claim contract, of which in is statementmade anapplication is part theentire has after made on based statements in anapplication thiscertificate this Wewillnotcgntest certficate its cancontest validity We of from for lifetime 2 years theDate lssue. the in during Insured's been efiect at to forfailure paypremiums anytime. is by coverageadded rider. occurs if will period coniestability apply reinstatement or additional of A new orfor for made onStatements in theapplication reinstatement based this Wewiltnotcontest certificate from for lifetime 2 years the the during Insured's in hasbeen effect after certificate coverage this additional in For coverage. anyincrease date from effective of theadditional the or date effective of rlinstatement will by added rider becontestable. coverage only coverage, theadditional has that unless rider itsownIncontestability to applies anyrider provision Incontestability This provision apply, will case rider's that in which Drovision, the exercised, being OPTION REENTRY certificate's of as was lf thiscertificate issued a result a prior to: will contest belimited that of amount insurance wemay less . TheFace of Amount thiscertificate; purchased the as would for year premium thiscertificate have that r Theamount insurance thefirst of premium certificate. the I next under prior annual reinstated' has if will limitation notapply thiscertificate been the However, above
lncontestability
of Misstatement or BirthDate $ex
willbe death this or birth asto a has lf there been misstatement theInsured's date sex, certificate's benefit or birth for bought thecorrect date sex' paid have the to adjusied what premiums would
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Assignment
on To or of for Wewiilnotberesponsiblethevalidity sufficiencyanyassignment. bebinding us,an Your Beneficiary. irrevocable to and Request consentedbyany must assignment bebyWritten executed may of thecertificate Assignment to interest rights anyBeneficiary's willbesubject theassignment. and and subject to income gifttax. You date Theeffective for: Date. will application bethecertificate provided theoriginal . coverage in provision. Date in . Reinstatementbeasstated theEffective of Reinstatement will effect thedate on will or owner, Beneficiary take contingent the to Request change 0wner, Anywritten died has or the who signed, if theOwner signed request theInsured since even was therequest origrnally was by the taken usbefore request made to willbesubject anypayments or actions the However, chanfie received recorcied. and in in of orotherwisetheevent a change the for of the Wemayrequire reiurn thiscertificate endorsement change' or option, other Beneficiary, settlement Owner, Contingent Owner,
Date Effective
changes certificate
of Claims creditors
paid, no this you assigned certificate, benefit to permitted lawandexcept theextent have by Totheextent of to or payable, besubject anyclaim process lawbyanycreditor. will or to become will of to or this or under certificate,anyamendments breach thisceftificate, be arising Anycontroversy in held state residence, of and arbitration in your exclusivelyfinal binding by determined settled and proceduresJAMS/Endispute successor. arbitrators its The or of rules with accordance thearbikation and judges, award panel Any rendered through arbitration from willbeselected JAMS/Endispute's of retired judgment beentered may thereon any in involved, and on and and wi1 final binding each allparties be jurisdiction. court comPetent of events: of will This certificate endat theearliest thefollowing payment' period without receipt required of . Thegrace ends for r Thecertificateexchanged a newcertiflcate' is for term. is renewed another the term r TheExpiration ofthecurrent unless certificate Date . TheInsured dies. r TheGroup terminates. Contract for is unless certificaterenewed another this Date on is Coveragenotin effect theExpiration of anyterm term.
Arbitration
TerminationCertificate of
Nonparticipating
will or No in does This certificate notshare ourprofits surplus. dividends bepaid.
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OWNERSHIP
$uccession Ownership living to wiilpass theperson(s)then of certificate ownershipthis atyourdeath, the lf youdiebefore Insured, which follows: intheorder . Any joint owne(s). n AnyContingent Owner. r Estate thelastOwner Die, to of persons will person then rights to succeeds theownership of thiscertificate, such lf more onenatural than unless prior willcontinue Owner of the ordesignations Any Owners. instruciions as ownthiscertificate joint Owner. by in with changed accordance thiscertificate thesucceeding Rights Ownership you is the While Insured alive, may: . Exercise of therights this under certificate. any r Assign certificate. this r Subject ouragreement, this or change amend certificate. to Owne(s). of consent anyjoint to right of Theexercise anyownership is subject thewritien and of Change Owner Owner Contingent any ownership, . Requestlf youtransfer by ownership Written you transfer is WhiletheInsured alive, may you in may A willbecanceled. change ownership subject to income Owner of earlier choice anyContingent andgifttax.
BENEFiCiARY lrrevocable Beneficiary is Beneficiary of The Beneficiary. consent anyinevocable an may AnyBeneficiary benamed inevocable the except following: the assigning ceriificate, right, any neided exercise ownership including to payment. . Change frequency premium of the r Reinstate certificate. this Beneficiary or the and you is change Beneficiary anyContingentirrevocable While lnsured alive, may ihe change to anysuch consent must written Inevocable Beneficiary(ies) give Request. byWritten any facts about age, as evidence totheidentity, andother require we any making payment, may Before evidence payments on based that to Weareentitled make person ctass as designatedtheBeneficiary, or
of Change Beneficiary to Payment Beneficiary
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PaYments Premium
Allpremium PaYments: their on . Must paid orbefore duedate' be .MustbemadeatourHomeofficeoranyadministrativeofficethaiwemaintatn' of States Amenca' of . Must inthecurrency theUniied be .Maybemadebyacurrent|ydatedcheckormoneyordermadepayabletoFide|ityandGuarantyLif ComPanY. lnsurance
Beforeanyinsurancebecomeseffective,thefirstpremiumforeachtermmustbepaidwhilethe|ns alive. on a Wewillissue receiPt request' for Th* quarterly, molthll.i1t9l1lti charge drfferent or semi-annual, premiums bepaid annual, ai may inthe INFORMATION RIDER AND PREMIUM, cERTlFlCAiE, unoer rr1own int*,urrr'ir payment premium on interval anycertificaie payment you may thepremium change section. INFORMATION CERTIFICATE anniversary.ourconsentisneededifanychangeresu|tsinapremiumoflessthan$25' Renewal term' Date is term dueontheExpiration ofthepreceding for Thefirstpremium each
if: term renew will coverage automaticaily fora 1 year and Thelifeinsurance rider INFORMATION iNthc INFbRMATION CERTIFICATE AND PNCVIUI'I*, RIDER r UNdEr CERTIFICATE, may that it sectionindicates thecoverage beconiinued' term premium thenew for paid been andtherenewal term expired have for r Allpremiums thepreceding hasbeen Paid' rTheExpirationDateofthenewtermisonorbeforethecertificateanniversaryonwhichthelnsure Age95.
of Adjustment Premiums Renewal
Period Grace
in the PREMIUMS CERTIFICATE RENEWAL OF in are premtums shown theTABLE ANNUAL Renewal under shown Period Guarantee year the certificate after Premium For section. each INFORMATION the to the wereserve right change section, INIFORMATION DATA CERTIFtcATE intheCERTIFICATE but that than shown, the or bemore less in shown thetable.lt may il;r; Life current lnsurance CunentT0ia|Premium*i-rr.n*u*'.bemorethantheGuaranteedMaximumTotalPremiumshown of notice the written address last to youatyour known year, each table.Before ceriificate wewillsend year' certificate due oremium forthenext of length time' the in effect same for basis allcertificates on will in Anychange premium bemade thesame or class premium in age Nochange Premtum class Premium andissue of to issued lnsureds thesame change Each has or has health woriened occupation changed theInsured's necause on willoccur renewal and expense, persistency earnings, investment mortality, asto on willbebased ourexpectations future experlence, after premium theiirst' This to due period thepremium date payeach after a we willallow 31daygrace this by is premium notpaid theendof thatperiod' If perlod, a any during grace rn remains effect certificaie period' overdue the a dies Insured during grace due as will certificate terminale of thepremium daie lf the here' As benefit' used the from death will from premium itsouei# io theendof thatperiod bededucted notice' premium i'premium" billed actually in the the means premtum
I Fage
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REINSTATEMENT
Reinstatement Requirements
provision, within it maybereinstated 3 years in Period as lf this certificate terminates provided theGrace premium. coverage "Reinstatement" to putthiscertificate's means of from duedate thefirstunpaid the back effect. into rider: and life under certificate anyattached this Wewillrequire each insured for r Wriiten for application reinstatement; Class shown under r Evidence ai Insured insurablethePremium is io us satisfactory thateach SCCIiONS thc INFORMATION iN PREMIUM, RIDER and CERTIFICATE andCERTIFICATE, DATA terminaied; and ihe section INFORMATION at thetime ceriificate CERTIFICATE annually. r Payment overdue at premiums interest their dates 6%compounded from due with of Dateof Effective Reinstatement Once for we the will Theeffective of reinstatementbethedate approve applicaiion reinstaiement. date last address: to approved, willmail youat your known we and I A copy thereinstatement date showing effective of reinstatement; ihe application of evidence insurability of r A copy anysupplemental been required as which have application rnay of
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of for maybeexchanged a newcertificate thesame this stated to Subject therequirements below, certificate atthat insurability time' of on raie at on nlan thelifeoftheInsured a premium based evidence of: the before later be cannot exercised option This or annlversary; r Thetenth certificaie Term. r Theendof thelnitial DATA CERTIFICATE in the under Date Reentry shown after be cannot exercised theFinal This option section' INFORMATI0N CERTIFICATE provided to, of, will this under provision bein lteu andnoiin addition coverage issued certificate Anynew begins' certificate the under new coverage when ends this under certificate Coveiage this under certificate. Wewillrequire: for application exchange' at be r Thatthiscertiflcate in effect thetimeof written before ceriificaie) prgllumonthenew payment theinitial of (including yourwritten for . application exchange section' INFORMATIgN in DATA theCERTIFICATE CLR11fICAIE unOei Date Reentry stated theFinat for application exchange' of thedate written on not r That Insured bedisabled the is that to us, . Evidence satisfactory andat ourexpense, theInsured insurable' t0 . Surrenderthlscertificateus. of will certificate beissued: Anynew the Daie . Witna Certificate asof thedateweapproved reeniry' Date' Certificate age . At theInsured's onthenew Date' Age at issues thelnsured's onthenewcertificate for rate . Atthepremium ineffect new of on for qualifies based evidence insurability' class . AtthePremium thelnsured than minimum the but of certificate, notless Amouni this the than Face to equat orless . Foranamgunt for required thisPlan be benefts additional rider that may for applicatronexchange requesi anyavailable providing written Your on using thenew raies and to sublect therules premium weare Rn! certificate. rideiis to attached thenew Date. Certificate provisionthe in and section theIncontestability BENEFIT provisiontheDEATH in Exclusion Thesuicide the under is certificateissued provisions if a new apply pRovlsloNi section how describe those GENERAL OPTION. REENTRY
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New Individual Policy
of premium, the lf theInsured's or other non-payment coverage anyportion it ends a reason than of for life you have issue policy individual of 2 us a orthose in number below, may Insured's age, described reasons thelifeoftheInsured. insurance on Anynewpolicy: r Must ona plan of at offered usforthispurpose thetime conversion, by being be r May beterm insurance. not . May beanamount certificate, greater theInsured's coverage thegroup under than not policy to include: is only Evidence insurability to us satisfactory willberequired if thenew of r Anyrider providing benefits. additional additions. . Anoption apply term insurance one to to dividends purchase year policy the under group his/her coverage policy after 31 for must TheInsured apply theindividual within days age policies, Insured's andclass the for of premium, on paytherequired based ourtable rates such ends and of risk. this dies period. thelnsured during lf policy at Theindividual willtake effect theendof the31dayconversion to entitled that of the the Policy amount lifeinsurance youwere 31day'period, wewillpayunder Group then it policy issued,will is policy, such lf for applied theindividual whether lnsured the not convert, does matter lt Policy. under Group the benefits for beinexchange anyfurther ,¤ ³ lf theInsured's coverage to or Policy terminated,is amended terminate is the ends coverage because Group 5 we for Policy atleast years, will theGroup under has covered class, fortheInsured's andthelnsured been The listed and conditions limitations above. face subject thesame to life issue policy individual insurance a of of Policy, anyamount less the amount under Group policy to amount theindividual willbeequal theface of or he/she Policy terminated,forwhich is the on iseligible thedate Group he/she group insurance which for life termination. 31 of within days such becomes eligible us may the is years, while certrficatein effect, Insured request to convert this and During fust10certificate the to subject thesame policy. willissue policy thai We life group to coverage anindividual insurance his/hei 1 stated conditions in number above.
and Suicide Incontestability
as dates those effective the wilt and provisions suicide incontestability have same for Anynewpolicy's provided rider, any by benefits policy any contains new if the Hpwever, new provisions inthiscertificate, have date. effective on will provisions suicide incontestability new in such rider stari thatrider's for and
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payment of Benefit Death
Ofiice. payment thedeath at will benefit bemade ourHome of Wewillrequire: Date the and is in this . That while certificate effect before Expiration of anyierm; death occur lost has that stating thiscertificate been or (ona formweaccept) . Return thiscertificate a certification or of destroYeo; and we death r Proof theInsured's ona form accept; of benefit' . A Written for Request thedeath death at to benefit bepaid theInsured's willbe: Thedeath in . TheFace Amount effect; Plus plus provided rider; by . Anyadditional benefit less was unless premium waived; the of month death, paid the . Thepart anypremium beyond Insured's of within grace the if occurs period death theendof thegrace to from premium itsduedate r Theunpaid Period of living to due benefit willbepaid theperson(s) onthedate such any to Subject anyassignment, death which follows: in death theorder r TheBeneficiary . AnyContingent Beneficiary, estate. r TheInsured's the after 10 or time dies Beneficiary at thesame asthelnsured within days or Contingent lf anyBeneficiary or Beneficiary such had as be 1re of death theInsured, oeithbenefitwiil paid if theInsured survived Benefi Contingent ciarY'
Paid lnterest on Death Benefit Exclusion $uicide
law' by benefit required state as on will Interest bepaid thedeath the or of 2 from within years theDate lssue from sane, insane, or while dies lf theInsured bysuicide payment we willbepaid.lnstead, willlimit benefit if any, reinstatement, nodeath date effeciive of theiast to: lite; paid on . Thepremiums forbenefits theInsured's less other theInsured. than on paid r Thepremiums forbenefits anyperson suicide, of on must certificate bein ef{ect thedate thelnsured's This if: will the However, exclusion notapply and being OPTION exercised; REENTRY certificate's a result a prior of was as r This certificate issued this if any, date passed theeffective ofthelastreinstatement, under from have r More Z years than prior certtftcate. or certificate the that it citizen unless canbeproven to was if provlsion notapply thiscertificate issued a Missouri does This for. was this when certificate applied suicide intended theInsured
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Payment Proceeds of
payable bepaid option under settlement rather a When Insured alior part anyproceeds dies, may of the than a lumo in sum.
payments settlement 1, to options 2, 3,or4. lf the Wemayissue annuity an under contract provide payment bemade aninterest-bearing payee(s) will into to a sum, ouroption, at elect(s) receive lump Thepayee(s)willbeabletowithdrawallo checkingaccountestablishedinthename(s)ofthepayee(s). part theproceeds theaccount anytime, at of in Interest Paid on Proceeds Payee of Election Option law. lnterest bepaid theproceeds required state will on by as of Thepayee(s) betherecipient thedeath will benefit. you option effect at a is Request, orchange settlement to take elect by While Insured alive, may, Written the you may The of the thelnsured's death. recipient thedeath benefit notchange election make.lf nooption one benefit elect byWritten Request. may is ineffect theInsured's at of death, recipient thedeath the proceeds start. be after 1, under options 2,3, or4 cannot changed payments Anelection receive to That effect thedate request signed, on was the After record opiion we any it election change,willtake or we the taken usbefore receive request by or will made action or to election change besubject anypayment andrecord change. the payments under monthly showing guaranteed the options follow. table Descriptions settlement of the A at options beoffered Additional may settlement follows descriptions the options. ofsettlement each option proceeds payable. thetime are
Option 1 lncome a for Fixed Period Optiqn2 LifeIncome a With Period Guaranteed Qltian3 lncome Life
5 which notbeless may chosen, than years of and for Payments guaranteed thenumber years months are period, death consisting of benefit years. thepayee before endofthefixed a the lf dies normore than 25 payments, scheduled, bepaid. guaranteed will remaining as annuity the 5 nor may than years more chosen, which notbeless for Payments guaranteed thenumber years are of period, payments continue aslong will for is at 25 lf than years. thepayee alive theendof theguaranteed period, death benefit, consisting a dies is the asthepayee alive.lf thepayee before endof theguaranteed payments, scheduled, bepaid. will guaranteed as annuity of theremaining after payee's the will is No will for as Payments bemade aslong thepayee alive. payments bemade death. will: The is or as the for Payments bemade aslong either payee jointpayee alive. payments will payee alive. are r Bepaid a jointlifeincome and while thepayee joint both amount in as payee theraterequested foraslong theremaining and . Continue bepaid at of to after death either the payee joint payee survives. or payee. . Cease thedeath both payee joint and the of at
Ortian4
JointandSurvivor Lifelncome
Page 14
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(Cont'd) OF METHODS SETTLEMENT
0di.onl lnterest
death' payment thepayee's at made or by until the we willhold proceeos withdrawn thepayee wehave for the we request, willhold interest up on out proceeds bepaid aselected, will on credited those Interest than frequently monthly' paid more no may payments be lnterest payment, to toyur6 without payments we byrequest' willstop at of all may Thepayee withdraw or part theproceeds anytime'Also, 1. under as will to interesi date bepaid described option proceeos and and this under option tneremaining to in will interest, bepaid onesum thePayee's plus not any dies, amount yetpaid, anyunpaid lf thepayee estate.
|
of Amount PaYment
on option a under settlement willdepend the: received of Theamount payments r Amount Proceeds of Payable; r Settlement chosen; option chosen; r Paymentfrequency ano 2' if are life over of birthday theperson whose payments made Options 3' or4 ate . Sexandage'nearest cnosen. OF in reflecied theTABLE GUARANTEED rate and the cornpare mortality interest factors we willthen premium immediate for rates anysingle in reflected thecurrent to .., PAYMENTSth; fa;tors MONTHLY wilL The to eligible purchase' payments would be the and offer which payee men we which may annuities payments' in result higher factors on bebased whtchever of annuity and option the will $enr contract tothepayee show settlement andamount frequency Anyannuity is contract issued' the as will pu,,**ni*, of which befixed of thedate annuity urr
Fayment
will: for Payments anoPtion Office' r Bemade theHome ai or r Bepaid check draft, by or of birth and/or date anypayee the proof existence of We any making payment, mayrequire Before lnsured. if: will any under option berequired for consent payment our ln allcases, written or trustee' assignee' association, partnership, is r Anypayee a corporation, than us $2,000' r Theamount with is less left payment less than $20' is . Anyannuiiy interest 0r
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for Applied Minimum Amount Each $1,000
"a" rate Table for lndividualAnnuities, Payments based a 3%effective annual interest andthe1983 TheGuaranteed Monthly are on . Income a Fixed Perlod For Period Payment ffears) ·N ,^ ·j S1795 ,· Ò 1518 ,V ·OE 1320
Period ffears) , W , X · , ]O
Period Pavment $ 1 1 . 7 1 1056 964 ·u ,P ·@ n ,y ·@ ,¤ ·e S689 553 472
2. Lifelncome Period Witha 10Year Guaranteed Aoo Female Aoe Male · · R,XO , , , O
, , , , P Q R S $424 4 . 3 1 439 447 456 , , , , R,XU , S,O , R S,O , X S,PU , 55 56 57 58 59
Male
S465 474 484 494 505 $424 432 440 449 458
Female
, ,O U , ,T U ·N , ,O V , ,T V
Male $5.17 5,84 665 754
Female
$463 525 600 693
3.Life lncome
Aqe , ,TO , ,TP , ,T¤ , , ,TT , ,TS Male $429 4.36 4,45 453 463 Female $392 398 405 412 419 Aoe 55 56 57 58 59 Male S472 483 494 505 518 Female 5427 436 444 454 464 60 65 70 75 Male $531 614 729 891
Female S4,74 539 629 763
4. Joint and 500/I Survivor Life income , l ,··] ,... ·@ , o· ·@ , ,u ¿ ·¡ ,O Ò ¯ ,T Ò n ,O ,O ^ê ,T ,U ·j ,O ,V ·OE ,V ,T ·OE $410 429 451 4.78 510 544 $428 449 474 504 539 578 Female Joint 75 $549 583 626 680 745 822
$450 473 501 535 575 619
$477 503 535 5,74 619 6,71
$510 540 576 621 6.75 737
on will sex, ages, andrates befurnished request. of years, combinations for amounts other Payment
16 Page C(12·] 99) FGL RTRC·]
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 22 of 39
Benefit Accelerated Rider
it to rider This is paftof theceftificate which is attached' MAY PAYMENTS BENEFIT IS BENEFIT PAID' ACCELERATED THEACCELERATED WHEN WILLBEREDUCED BENEFIT IHEDEATH ADVICE' FOR A CONTACTTAXADVISOR SPECIFIC YOU BE TAXABLE. SHOULD DefinitiOns DATA CERTIFICATE intheCERTIFICATE under as The lnsured, Insured(s) shown section INFORMATION of thecertificate. of Yqq-YgUITheOwner thecertificate, has if this payable youunder rider thelnsured a Terminal to The Benefit. amount Accelerated lllness. Ehgjb!4nqqil'Theamountpayab|eunderthecertificate'sDeathBenefitonthedatewe Benefit the your approve requestfor Accelerated Amount The you Amount request' Accelerated of The Amount. portion theEtigible Accelerated of: the maynotexceed lesser or Amount; r 500/o iheEligible of . $250,000. who A of Phvsician.doctor medicine is: qualitied; r Duly and of States America; . LicensedtheUnited in of . Performing thescope hisor herlicense' within of or parent, spouse child either sister, the the must A Physician notbe: you, Insured; brother, of or youortheInsured; anyspouse anyoftheabove' a having lifeexpectancy in that condition results thelnsured or lllness physical lllness. Terminal or of 12months less. Date Effective AND PREMIUM, RIDER under cERTlFlcATE, shown 0n is rider effeciive thedate This of thecertificate' section TNFORMATION inthe TNFORMATION cERTtFICATE we the Before pay Acceleraied Benefit. for Request iheAccelerated a we willrequire written has the to us proof with satisfactory that Insured a us that we Benefit, willrequire youprovide who by to, butis notlimited certificaiiona Physician include, This lllness. prooiwill Terminal lllnessWe Termlnal with inconnection thelnsured's care medical io thelnsured provides from at our certifrcation, expense, a Physician medical a t0 l*r*ru* theright obtain second bY selected us. sum Nofurther to Benefit youin a lump we your lf weapprove request, willpaytheAccelerated the is Benefit paid, the dies will this under rider bepaid,lfihe Insured before Accelerated benefit paid under willbe no with in will benefit bepaid accordance thecertificate; benefit oeattr entire thisrider,
and Request Written lllness of Froof Terminal
Benefit
96) FGL AB5-C13·]
1 Page
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 23 of 39
d) Rider Benefit (Cont' Accelerated
(Cont'd) Benefit
Benefit is; TheAccelerated period; less over r Thevalue theAccelerated Amount discounted a 12month of r Anadministrativeof$350; fee less your for we if on interest,any, thedate approve request r A portion anyunpaid and loans loan of by Accelerated Amount the by the is Benefit. theAcceterated flhat poriion determined dividing and loans loan by multiplying percentagethesumof unpaid that Amount, then and Eligible interest ) Amount: the when the Wewillconsider following wediscount Accelerated and premiums thecertificate; for . Theexpected future monthly of: than will r Interesi anannual declared uswhich notbehigher thegreater by ai rate - Thecurrent on90-day or Treasury bills; United States yield - Thecurrent loan rate. certificate interest statutory adjustable maximum
·\ m ·d ·\ g ·[ ·[ g ·[ ·[ ·[ g ·[ ·[ ·[ ·[ ·[ ·d ·\ ,h ,d ,d ,h ,h ,d ,d ,d ·¡ ·¡ ·¡ ·¡ ·¡ ·¡ ·¡
Adjustments to Values Ceftificate
amounts The the Benefit notterminate certificate, following does Payment theAcceterated of t0 Amount bears proportion theAccelerated that will in the under certificate bereduced thesame theEligible Amouni: . TheFace Amount: and . Theaccount orcash value, applicable; as value . Anyunpaid interest' loans load and Face to the will Premiums bereduced reflect reduced Amount' of which a part the is payable under rider any the amount we Inaddition, willreduce monthly provides fordisability. benefits certificate which and due page(s) reflecting changes to payment INFORMATION Wewillissue revised CERTIFICATE Benefit. of theAccelerated
Conditions
conditions: to Benefit subject thefollowing is Payment theAccelerated of we before approve must from r Anyamount keep certificaie terminating bepaid the needed to your Written Request. or we of (on . Wewillrequire written consent a form accept) anyjointOwner lrrevocable the in interest thecertificate. having an Beneficiary for except us,assecurity a loan. to . Thecertiflcate notbeassigned anyperson, to must you ihird to to is Benefit notmeant allow parties cause to of Payment theAccelerated Therefore, payable thenamed Beneflciary. t0 ultimately benefit invade death the invbluntarily for youarenoteligible thisbenefit: in whether of the to . ttyouarerequired lawto usethisbenefit meet claims creditors, by or bankruptcyotherwise; or for, or in to to r youarerequired a government agency usethisbenefit order apply obtain, by or benefit entitlement' keep government a
(3-96) ABs-C FGL
Page 2
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 24 of 39
(Cont' d) Benefit Acceferated Rider NonPaltlcipatlng Dividends are nOt payable. OWing end atthe earllest eventsi lination ThlS rider wi·a ofthe ib·a Rider Ter·¡ o The cel1lcale terminates. .The Acceleraled Benefltis pald. ·oe Wntten RequeSt Your
of confirmation changes benefits, to of any confirmation changes thisrider's address your we willmairto lastknown date the including effective of anychange
for $igned theQonPanY.
Company Life and Fidelity Guaranty Insurance "§ · Ë m, È ·E m
FGLC(3-96) AB5·]
Page 3
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 25 of 39
Rider of Return Premium
PRE CERTIFICATE, IIUM,ANDRIDER rs under The it to of rider This is nart theceftiftcate which is attached. premiumshown provsons all as ln Excepf stated thisrider, othercertiftcafe section TNFORMATTON of theceftificafe. in the TNFORMATION }ERTIFI}ATE appty PREMIUM, RIDER AND under CERTIFICATE, asshown Dependent(s) The Dpended. Covered Cqvqed section INFORMATION ofthecertificate, intheCERTIFICATE TNFORMATION Date on is This rider effective the certificate's of lssue. Benefit the ends benefitthecefiificate after fifth if of we is this While rider in effect, willpaya Return Premium will beneflt of Date. of Expiration Theamount theReturn Premium year the ceriificate andonor before initial premiums) thepercentage shown rider (including times any paid of bethetotal premiums onthecertificate PREMIUM, CERTIFICATE, shown under upon The differs below. percentage depending theiermperiod of of The INFORMATION section thecertificate, Return in the TNFORMATION CERTIFICATE ANDRTDER premium such to paid under rider any attached thecertificate, by benefit bereduced anyamount will is if of benefit payable However, Return Premium no benefit, of the not reduciion to exceed Return Premium is this dies Dependent while rider ineffect. or anyInsured Covered the on of in than is benefit greater iheamount insuranceeffect thecertificate, of lf theReturn Premium benefit. of to of will of amount insurance beincreasedbe105% theReturn Premium endof year certificate 1S-year term certificate
2O-year term certificate 0·< /0 3% 6% 9·oe /·B 120/. 15·< /1 22% 29% 360/. 430/. 500/. 600/. 70% 80·< /·oe 90% 1000/0
25-year term certificate 0% 20/·oe 4% 6% 8% 100/. 13·< /1 16% 19% 220/0 25% 30% 350/·B 40% 450/0 50% 60% 70·< /1 800/0 90·< /1 1000/.
30-year term certificate 0% 1% 2% 3% 4·< /·oe 5% 70/·B 9% /· 1 1 0< 13% 150/0 17% 19% 21% 23% 25% 30% 35% 40% 45% 50% 60% 70% 800/0 90% 1000/o
T ··,] N ,U ,V ,W ,X ·, ]O · , ]P ·, ]Q ·, ]R ·, ]S ·, ]T ·, ]U ·, ]V ·, ]W ·, ]X , ,Q O , ·Q ] , ,Q Q , ,Q R , ,Q S , ,Q T , ,Q U , ,Q V , ,Q W , ,Q X , ,R O
0·< /1 5% 100/0 150/0 200/0 25·< /0 400/0 55·< /0 700/·E 850/·E 100%
99) FGL R'1-0(3·]
Page 1
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 26 of 39
Return Premium (Cont'd) of Rider
Benefit New Certificate Option payable rider be to the of lf youterminate certificate, benefit any under Return Premium may transfened a this policy. new policy, provided Return Premium is part thenew will rider The new of benefit bethegreater of the of: r Thesum thepremiurns under certificate thenewpolicy, paid multiplied thepercentage by shown of and this provision) thepolicy andthethen (under rider's number years of Benefit for ierm current the inthetable this policy been effect, new has in or r TheReturn Premium payable is this if a of benefit under certificate newpolicy notpurchased, provision, Grace year lapses provided theceriificate's Period as in After 5thcertificate andif thecertificate the have of benefit, notmore 60days lf than thecertificate have cash value to will a equal theReturn Premium passed premium's date, of twooptions beavailable: due one will since unpaid the - The r Cash for value. cash is to The value equal the may Surrendef certificate be$urrendereditscash your or Return Premium Request return thecertificatea and of of benefit. willrequire Written We lost (on that has ceriification a form accept) we stating theceftificate been ordestroyed. - lf r Extended Term Under option, this will this Level Insurance nooption selected, option beautomatic. is period youmay The level insurance. term will as extended term continue certrficatenonpartrcipating the premium. period bedetermined applying cash value a will as siart theduedate theunpaid of That by the on premium such will and will the for in$urance. theendofthatperiod, insurance terminate there At netsrngle benocash value remaining. provided may for Levei Option besurrendered itscashvalu Anyinsurance the under Extended Termlnsurance within premium theinsurance remaining. lf such I for surrender occurs The value equal netsingle cash will the value that on the anniversary. than cash anniversary, value notbeless the will days a certificate after Wewillrequire: r Your Request. Written has lost r Return thecertificatea certification a form accept) (on that stating thecertificate been or we or of destroyed. your payment thecash for value upto 6 months wereceive Written after of Wereserve right defer the to rate law, than minimum requrred state if ihedefenal by at not the Request, willpayinterest a rate less We period 30days more. is or on: the based Cash equal exceed values value amounts or . 1980 Nonsmoker Smoker and Tables; CSO r AgeLasi Birthday; . Interest of 5.75% year, per rate . Death year occurring theendofthecertificate at on: is Extended LevelTerm Insurance Option based r 1980 Nonsmoker Smoker Tables; and CET . AgeLast Birthday: . Interest of 5.75% year; per rate . Death year at occurring theendof thecertiftcate A is this by in required thestate which certificatedelivered. detailed or those Certificate values equal exceed departmentthat of has filed the values been with insurance those used statementthemethod to compute of state.
Nonforfeiture Options
Surrender of lnsurance Under Extended Level Term lnsurance Option
Deferral of Value Cash Payment Basis Certificaie of Values
FGL RPl·] 99) 0(3·]
2 Page
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 27 of 39
(Gont'd) Rider of Return Premium
Nonparticipating Termination Rider are Dlvidends notpayable' events: of will This rider endattheearliest thefollowing . Expiration of theinitial period. term Date goes effect, into r AnyNonforfeiture Option . Your Request. Written . Thecertificate terminates. . AnyOther Insured dies. including the benefit, to of any address confirmation changes thisrider's last to Wewillmail your known change' date effective of anY
of ConfirmationChanges
for Signed theComPanY.
Company Life and Fidelity Guaranty Insurance "§ m" G ·E m
President
FGL RPl·] C(399)
3 Page
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 28 of 39
Fidelity& GuarantyLife InsuranceCompany ice SeW Center P,0.Box 81497 1497 Lincoin,NE 68501·]
DELiVERY REQUIREMENT(3) October 12,2005
Pollcy Number: L0531119.Sean K owing requirements must be rnet within Keelithe fo·a our Service 30 days to activate you·u you have any questiOns feelfree to ca·a Policy. lf Center at l-888-513-8797.
premium $378.30' of with a quarterly Folicyis beingissued of in lnitialpremium the amount $378.30. Need
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 29 of 39
3,?005:9:41Alv11 SAN fRA·a Rr6-i0CT. Case 3:07-cv-04723-MHP
+
CISC0 923
Document 28-6
Filed 02/29/2008 Pagel. 30 of 39b ·A6 T·oe OFFICES> i"¿ It 2/ m
2/,à
Pararnedical $upplement Application to
Life Compahy f#ldelity anrlQtErsnty fnrurance
tits; lt{xvng Mi.'rfl+lnitill
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paln, preSsrlftr, cholesterol s) Anyhean rliscase high chert blood helrrafinck, hlgh murnrur, p*lpilrtinn.c, aoyorhar vessdsf dr of or diporder thehoa6 blood rlisorder lhcveiru artetlesT or TlA, oranyother of b) r irr-ullrory disenre, strokcr
bronchldr..r s) Any hrearhing lungdl*order, UUPD/ilsthma, or rtr of of blooddisordcr, dldordel the systcln. d) Diabettudisorder th+ immune el ,É arlCeL curTl·oe I·E L·oe
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2. AtHyou cursnll/ prc"cerlbErl medicationl nny ir) 3. H*ve you hc*n proscribecl medicarlorr the 10 4, tn lhe past yeerF. havcyoul hotfJiralizEd hadsurgcryl or ai tsecn
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Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008 I s ¯Pagel 311 ` 139 6 S T OE ·F F · q >: l " N l ` of OE =û l
- Continued
10.Personal Phy+icifrfi'* andAddrecs: Nnrne
Ddrc nnd
Cenrulred; Lq$t -_Hn#
( ,
aliF___,² ZO ZO L5_·c __·c --M ZR Renl w·¡ ·a,¯·oe l Å ·¡Orlned,¡ ,°on presc·a ,Sì"sb b·oe "ñ OE^ ·c·cj·[ ·[ _sM ·c·o·\ ^ê·c·csM ·c ·c·c "ñ·c
S·OE dR a diagnoS ler durttHan·OE upproprlarc: where ·b m<~ end number inclurlc 1 111 Givs Sbrfe ilnfi#ers. qUesilon ol details /Yeg" fu+ilitiesl and physlcianr medleal of anda.ldresseslll atrendlng
^ê
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Signrd {C'ily $LateJ ot and on
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Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 32 of 39
orB) Life lnsurance Application (pase1
Cornpany f-idelify& Cuurantylifs Insurance Nalne(Fir5t M I 51 L·¡ 3·oe ·¡n,,K.Keel " Home Add"ì
á í ' PI '
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91124-." --* - 14$0. | 5 t . ; i Avenue ;5altlgrylecsr-tA- , l J a t c o f B l ( h t , t a . l ' i i E 1 i i i i . , | r r t , , i * r ; n , . ' ' g t ' . t t [ o l ' 5 d t Oakdde r y T ; . _ # ' i ' ' f f i * ; . i i
| 200 .'' +ilo" .-.: trlarrieo -l oe'r+::* :--il sr0,1?-$s45----l---lt1l, G ; r " f f i # r # ; i - - - - E ; p s i l i r i , . ; ; J i , ; r - - ' * ' - - " : : l t i : : : - - l v i ' r f w i c ' " " " m r ' i ' i ? i wq_ r '"ii"J*i'*'.-5*r,,1., pacific Eree!o.lF__*__l** . I ion*t.u"uon _ | "
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Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 33 of 39
or$) Life lnsuranceApplication (page?
pftlducl Namc I
n I lnstl,¡ Ce Amouilt·oe nmount oi In$urnncg
l ln·a I
id Premlurn rr'rrrs"t rrrrrrirr
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Monthly PaPut $ l} 3 rnonth elimination, 2 year benefit D 6 rnontlrelimination,5 year bcnefit
dl Retumof PremiurnRidcr
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of: Monthly InCome $ lor yCars FinalLtrmPSurn:$
//s5traticrn rcquircd.
Rider O Waiver of Monthly Dedr'rction (Ut"onlY) D Waiver of PrentiunrRidet (Ternr onlyl O Clrild Rider (J Other: AmOunti rcqilifcd quc'etionnatie 5u pgiementdl
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 34 of 39
3or Life Insurance Application (pasc 8)
· d (Nolaçp "s"e
with all producls gr in all rtalts) av.rilable
Rider O OtherlnsurxVDePcnrlent
fJ DirabilitYIncome Rider
Amount: $
Icrm Feritxl:
yrs,
Fol tenn products,leffn perio{t must matclr ba.cePolicl tem Peti}d,
Morrthly lbyout: $ O 3 mqnth elirnination,z year benefit t) 6 month elintinatlon,-5year benefit
1· · W ² ãJ 1 · g , ¦ . · a· ¡ E O N , · ·· V" i m c u v · g·ºoe
or Litc lrtSUr,rnCe DisebilitY lncornt'Ailutll
AIJII Ailrolnt _ , .Ycar lrsu{
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l~b ^Å 1Q O N O Y O N
or life.insuranceannuityf any or replace, change existin8 if issued, will thisPolicy/certi{icate, or are irui;, J,.r.'nfiich policylcertific.ae(s) above to he replaced changed. listcrl ir
Anrount being rePlacerl $ dct'rils): applic.rtionpendingl (lf yes' provicie 2. ls nnv ollrcr insurancu for postFontd/ rated,mtrdified,trr refitsed Havc you had an/ insuranceapplicationtjeclined' tlf rcinstrtemenL? ycs, provide cletalls);
O Y
OY ON
OY ON
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OY ON
·\ ·\ ·\ ·\ ·d ,P ,P ,P ,P "ú ·\ ^ ^ ·¡ ·¡ ·¡
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 35 of 39
·, k O N Y OY ON c)YON OY p,,G C;;..;'F;'"'r;I'l':::ll*:,"!#',{-iilT1i1,;Jlt.fllil%i:li 5.i",h- il;h"'. I·OE W·" I·Ò ·y Z§ ntr·¡ m ,² ·ð yl·oe N OY ON l·i ,,[ZÈ ·OE u d'^ ·" Y·oe "û ·OE [·u ·£ ·c ^ê ·c ·è·ã ·u |àe ^ê ^ê ^ê^ê ·\ ·c ^ê ·c ^ê ^ê ON ral: or cFeW mCmherOY an aiÈ of loI·OE · ·B h...·B a ,µ ,ÍOEû :Past 5IÌ·va --· p11·< yc:áe Á w·u 5md,± 0,:n·a "IunãJ o,OE¤ adv,É lD E ON ·u recJ"d u ever::18ht·B treament |,¢10r the V i·v:·u :|:have,¢ 7.Zs alcoholl'p ·u ·S useof
below {adtlilional ht{ornntion may be retluircd)' Detai/ *lf ycs .rns-rryt't'$ tnarldition,rvlnplclcqut,r|ionrl,ritesforVfsr}fl5t#8f5trrQrrctfiorrst,5,and6. P·E -1 · ·oe CiLnt earn3 00,000 Ç W·aoe arn3 585=|||·oe ·oe m·aned ln,ome s12 =121
Other Inrqred
Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 36 of 39
E or Life lnsuranceApplication (pagen) l·E Iame JOEû , sb ,`,,ditll Welch M_D. ·D
irc',N0NfaifPriileD,inil|L\J(hNs,rdlhdyl',1P(T$rnrlpfipirjan-1
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Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 37 of 39
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Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 38 of 39
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and for life insurance' ls i'r,ranigsr, my uenerrr rwords,phrrmarry "mproyoito'gi"".* or anyrnembcr'"i"nyiii;iiv who applying ,*gi'LrT"5 1s whiclrnrayhe pertine*nr thq svaiuatiu" f'rmilywho is also'rpplyingfor informrtion nty coniutler "po't on tle il^'ol any menrber'of to otrtainan invq'Stigativc wlrichmry be requestetl prePare ug*ucv the I alsoauthorize Insurer.to by () i"t'ir*r t'iU* intqiu'i"#cd anv:..",,t-lT'*L:*l*iting if intervicw requeited: I unrterrtansi-hJtiii* ftq''jii' Chkli litu insurance, nd--t irusinets ct'ntatred'a'.,'iing +s illncss definedin *']l sucha re*rrl a5lsng as, .# ,.lion"'Uiy'he Rirler r'rJ',,erit antl l.am laterdiagnosecl ponitrnof nrv'encJ* early'tre iLolTintl the.Accelerarccr ,..,_rr]es thar I untJerstand if my."rorg* ir-r*ril sr_cei**rE receive.a a."i'r, rereiPt otthe c.ertificate drdt orb'+rnenu up I the rit,er, mayrccerve t, s-tiv" "r'|Jiily:, *irr*.TroY::ffiili'f?{',:ni*iil;iilit-t!*i*;*i"*,1*,;d
payahie ann,rnr attreti*re'Ir-riviiir'n
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Isrrppricd upon inforiration r,- aboutrny i,ilp,slrtilI:r*neu'u , in.rcr.'ia't" wir reried information iu.t l;"j#,,il1?1;.#fiI'i;.ilHffii*iltiT.-.r*,"',*nheahh inmrfiaHJf,-ni ,,,iv procluct, frrr my lnsuraD*ty rhar
which insurance to Inrav tor orher companics apprv trffin$il";l*;l;l,ll;'*ruJfo'i,',i;-:":lilH:;liifrT'.t maytresubmittctl' or will covcra8e to whicl'ta ctairn Authurization tE as healtt insurance of
copy this life or r"r'" p*ri"o of .tt) m'nrrrs;a phora6raphic wi, ThisAuthorizarion rrc v.rrid.irc* ,l* glg-liglP-o'--*n-tf,hd icccivea copyof thisAuthorization' to benefiti' and/or for valicl theoriginul;l, or flnyof our represenutiues as U*rmirre eligibility insurance by u" .,f'f i""'l'*'ization will t* "i-Ai" tlre on provirled thisform are Numbers I understandthat informiit'n otrt'rirted gocialsecurity rax tdentificatioa or 'il"*V of unclcrthe perraliiel PeriuryI certi{y certification:
true, correct arrd cnmPlete,
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Case 3:07-cv-04723-MHP
Document 28-6
Filed 02/29/2008
Page 39 of 39
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